Online Registration

General Information

• Name *
• Email *
• Mobile *
• Land Line *
• Company Name *
• Date Of Birth *

  E.g., 05/11/2014

  DOB Format : DD/MM/YYYY

Address

• Address *
• City *
• Pin *
• State * Select State Delhi / NCR Maharashtra Uttar Pradesh Karnataka Bihar Gujarat Rajasthan Jharkhand Madhya Pradesh Tamil Nadu Andhra Pradesh Chattisgarh Chandigarh Uttarkhand Haryana Punjab West Bengal Kerala Goa Pondicherry Himachal Pradesh Assam Jammu & Kashmir Orissa Meghalaya Mizoram Manipur Sikkim Nagaland Arunachal Pradesh Other Suryapet

Additional Information

• Current Occupation * Select Occupation Family Business Self Employed Job/Service House Wife Unemployed Other
• Current Occupation Other *
• Doing Business Since * Select Year Less than 1 Year 1 to 5 Years More than 5 Years Not Started as yet
• Operating from * Select Operating Form Shop/Office Home Door To Door Not Applicable Others
• Operating from Other*
• Leader of any society, committee or group * No Yes
• Education Qualification * Select Qualification Post Graduate Graduate Under Graduate Other
• Education Qualification Other *
• Applicant type * Select Type Individual Proprietor Partnership

Declaration

I hereby declare that the details given herein are true, correct and complete to the best of my knowledge and belief, the copy of the documents submitted stage are genuine and belong me. I hearby undertake to promptly inform Newspaper Ad Agency in writing, of any changes in the information provided herein above and agree and accept that Newspaper Ad Agency is not liable or responsible for any losses, costs, damages arising out of any actions undertaken or activities performed by Newspaper Ad Agency on the basis of the information provided by me as also due to my not intimating / delay in intimating such changes. I hereby authorize Newspaper Ad Agency to disclose, share, remit in any form, mode or manner, all / any of the information provided by me. I hereby agree to provide any additional information / documentation that may be required by Newspaper Ad Agency, in connection with this application. I also agree that Newspaper Ad Agency has the right to reject my application form on any ground without any reason.